The Podium
The Podium
6. Dr. Aaron Baggish - Exercise and Heart Health
One of the most frequent questions I receive from patients is, "How much exercise is too much?" We have all seen the stories or personally known someone who suffered a cardiac condition despite being extremely fit. Yet, it is well established that exercise is ultimately good for the heart. This raises the question of whether you can get too much of a good thing.
No one is more qualified to address this topic than Dr. Aaron Baggish, and he joins us on this episode of The Podium. Dr. Baggish, an athlete himself, is the director of the Cardiovascular Performance Program at the Massachusetts General Hospital Heart Center. He serves as team cardiologist / physician for numerous athletic organizations including US Soccer, US Rowing, Harvard University Athletics, New England Patriots, Boston Bruins, New England Revolution, and is medical director for the BAA Boston Marathon. When I have any question regarding Sports Cardiology, I go straight to Aaron! I'm excited and thankful to have him join us on this episode to discuss an important topic.
Welcome to the podium. The podcast about optimal health and high performance. I'm Dr. Kevin Sprouse. This discussion was created as a resource for the patients in my practice, where I have the pleasure of working with a very small group of professional athletes and high-performing individuals from around the world. So why podium? Well, it represents the pinnacle. The winner of any race takes their place to top the podium. Much as any expert in their field is often asked to share the wisdom and present from the podium. For me, it represents the intersection of athletic and cognitive performance. Our podcast dissects the principles of performance for my patients, and then disseminates, pertinent, actionable information with them in mind, if you happen to have found us and are not a patient, that's great. I hope you enjoy. Please understand if you're not a current patient. Any information contained here in is not meant for you to take as medical advice. You need to speak with your doctor before implementing any change in your health and fitness regimen. There is no doctor patient relationship established via this podcast from my patients. Of course, that relationship already exists. Season three of the
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Speaker 2:Welcome to this episode of the podium. When we first started this podcast earlier in the year, one of the topics I knew I wanted to address was sports cardiology and the risk around a long-term activity, the benefit obviously of exercise and how to weigh those two. And knowing that I wanted to do that, I also knew that the one person I wanted to talk to about this was Dr. Aaron Baggish. Aaron is a great guy and a world expert on this topic. He's the director of the cardiovascular performance program at mass general hospital in Boston. Uh, he's also the, uh, medical director for the Boston marathon. He serves as team cardiologist to us, soccer, us rowing Harvard athletics. Um, he's the team cardiologists for the new England Patriots, the Boston Bruins. I mean, he is, uh, someone who academically is at the forefront of sports cardiology, but also clinically and implementation of this stuff. Um, and he's an athlete himself. Uh, he's uh, an avid runner, someone who understands all aspects of this in a way that no one else does. So I'm really thrilled to bring this conversation to you, Dr. Aaron Baggish from the cardiovascular performance program at mass general. So Aaron Baggish thank you for joining us on the podium as an episode that I've had lots of people asking me questions about and, um, topics to address it's cardiology, sports endurance. How w how does all that come together? What, what are the aspects of heart health? So you are the man to talk to thank you for joining us. It's great to be with you. So before we get into that, tell me a little bit about the specialty of sports cardiology and how you got into it. Because quite honestly, when I was coming through med school and residency, it was not anything that was on my radar. Um, and really until we met maybe five years ago at Kona, um, I didn't really know it was, uh, a specialty in this sense other than someone just being interested in it. Yeah. It's been a really fun kind of evolution of a specialty. Um, you know, cardiologists have taken care of athletes for, for decades. There's nothing new about understanding that there's an interest in heart health and people that are athletic, but, um, it really hasn't been a bonafide specialty until the past decade or so. Uh, and from my personal perspective, I came at this first and foremost as an endurance athlete that had friends, training partners, people I knew well in the community that develop heart problems, went to doctors and just were simply unsatisfied with their experience. They were treated like heart patients rather than athletes with a heart problem. And so I set myself on a course of figuring out how we could set up resources for people like this and went through my training. And we launched a program back in the mid two thousands here in Boston called the cardiovascular performance program where we really set out to do just that. And that is to be a resource for athletes all over the country, if not all over the world to come and work with us when they had either a risk of a heart problem, a concern about a heart problem, or even an established heart problem. And what, what ensued relatively rapidly is that the powers to be at the American college of cardiology saw this as a need and turning this into a, a focus of kind of professional development for them. And now there are sports cardiology centers that most of the major medical centers around the country, which has been really exciting to see. And along with that has come a lot of research and a lot of writing about how best to do this. Yeah. I mean, to go from one program, which is it fair to say you over the first one? Is that what you said? It is fair to say to now a decade later having them, I won't say too ubiquitous, but like you said, at the major medical centers, major academic medical centers, um, that's a, that's a huge, uh, kind of growth in the specialty. And I think to your point, it really hinges a lot on the fact that so many athletes and not just professional and elite athletes, but so many active individuals with heart concerns, don't have anywhere else to go. I mean, there's such a need for this. I even here where I am in Knoxville, Tennessee, we ended up sending patients out. Um, you know, we've got Emory and Vanderbilt fairly nearby. Um, Indianapolis is not so far, uh, certainly send probably most of my patients to you, and you're kind enough to take care of them and, and tell me what in the world is going on, but it's so nice to have this specialty really growing and have resources for so many patients. I first kind of had my first run in with this while I was a fellow in sports medicine, I was covering a, a cycling team. They were a U 23 continental cycling team development team for the team that I worked for now. And we had a guy who passed out during training and he passed out at the top of manioc Hill in Philadelphia, which is a, um, it's a short, pretty punchy climb. Like it's all out. And I got a call, Hey doc, you know, this guy's passed out and I'm a fellow and I'm just learning about this stuff. I was like, okay, did he stop and pass out? Or was he like, he just fell over? No, no, no, no. He just fell over, like, not quite at the top. And so digging into it, this has happened to him five other times, and he'd seen doctors at five institutions internationally and also, no, no, no, it's fine. It's fine. It's fine. And so when I looked at all that stuff and saw, you know, he had hokum and when we looked at the hypertrophic cardiomyopathy, um, when we looked at the echo, the numbers jumped out to me as abnormal. And we got into a sports specialist who, uh, made the proper diagnosis, but in my head I recognized the same thing you did right there that, okay, this guy has had to live through five of those. That, that can't be that common. So to have all those second, third, fourth chances, and finally get to the right cardiologist, the others were knowledgeable and well-meaning, it just wasn't their specialty.
Speaker 3:Yeah. I mean, well, he was lucky that he had you to pick up on that. Cause the fifth one, he didn't survive the 61, maybe he didn't survive. Right. It's, it's, it's a scary story. And I think what it speaks to is that, um, even really accomplished cardiologists that know the field well and take care of patients with heart disease every day, um, may not be well-versed in, what's normal for an athlete. And there's this concept that most cardiologists understand of the athlete's heart. And perhaps we'll talk a little bit about that, but what's truly normal for an athlete versus what's physiologic Scully. Abnormal is something that a lot of cardiologists really struggled to understand. And so mild cases of hypertrophic cardiomyopathy are often misinterpreted as being the athlete's heart and vice versa.
Speaker 2:Yeah. So let's do talk about that a little bit. So what we're talking about here is congenital abnormalities abnormalities. Someone is presumably born with, as opposed to the acquired ones, which we'll talk about in a minute that may be experienced by an athlete after the age of 30, 35. Um, so often younger athletes, but not always things that you're born with. Um, how do we look for pathology? How does it present a symptom like in terms of symptoms, but also from a diagnostic standpoint versus what you mentioned athlete's heart, which is just presumably the heart growing as a muscle, like any other muscle as you, as you stress it.
Speaker 3:Yeah. It's probably worth just as we're talking about young athletes differentiating congenital from genetic heart disease because they are two different things that are relevant in this age group, congenital heart disease are really things that are structurally abnormal with the heart, that form during embryonic development. And those are usually pretty easy to diagnose issues with heart chamber sizes and configurations of valves. And we see some of that, but the, the biggest player, if you will, in young athletes are genetic things. They are born with that gene, but the gene materializes and becomes relevant as an abnormal heart at some point in their kind of teens, twenties, thirties. And that in hypertrophic cardiomyopathy is that is the paradigm example of that.
Speaker 2:Sure. That's a good point. So, um, that those issues of genetic, uh, genetic heart disease that really show up primarily, like you said, teens, twenties, thirties, usually in athletic individuals because of the demand they're placing on the heart, um, the demand isn't causative, but it kind of puts them in the situation where the condition presents, I suppose you see it in non-athletes also, but maybe not as frequently. Is that fair?
Speaker 3:Yeah, it's, it's quite fair. I mean, we, we see it in athletes more commonly because we test athletes more commonly, but these are not diseases that athletes are more at risk for developing than the general population. This is just luck of the draw genetics. If you had a parent that has the gene, you get the gene and you're likely to develop the disease. Um, we see it again in athletes just simply because we look under the hood more commonly. Yeah.
Speaker 2:So in those athletes, we're all familiar with the dramatic and tragic videos of people dropping down on the basketball court, in the soccer field, whatever, what are the, what are the things that get them to you, uh, symptomatically to, to, to look for these conditions.
Speaker 3:They come to us down one of two pathways. The first is that they're totally asymptomatic. And they went through some form of a screening test, usually a 12 lead ECG that finds an abnormality that leads to the diagnosis. Uh, and the second, which happens just as frequently as an athlete, either notices or is observed to have some symptom that's concerning. So exertional, shortness of breath, that's out of proportion to the amount of work they're doing chest pain, maybe a fainting episode, like you described in your cyclist and people and, or the athlete themselves are concerned enough about those symptoms to ask for an evaluation.
Speaker 2:Now, when I was going through fellowship, um, nine, 10 years ago, we were taught that one of the most common presenting symptoms of, of any of these types of abnormalities is sudden death. Is that still the case with the, the amount of screening, the increase in screening that's going on? Are we catching more of these?
Speaker 3:Oh no, that's definitely the needle in the haystack. We find many more living people with conditions, then tragic cases that we, that we diagnosed on autopsy. So I think it's, it's a function of screening, but it's also a function of, um, the general medical community and being more alert to the fact that athletes aren't immune to heart disease and realizing that symptoms shouldn't just be brushed off. W we get most of our referrals from athletic trainers and coaches that watch their athletes and say, something's not right with this kid. You should go see a doctor. And so we're finding a lot more people that are living with these conditions and dying with them.
Speaker 2:I think a big part of that is like you mentioned the awareness in the general medical community, um, when looking at STGs on, on athletes, it used to be, well, that looks abnormal, but it doesn't look too bad. So it's probably fine, you know, it was kind of, nobody knew the norms, right. And, and now, uh, there was, uh, a fantastic paper that, um, I believe you were an author on the Seattle consensus, is that correct? Yep. Yeah. So this, this was a paper that came out, um, a few years ago, 2016, maybe that, um, really codified, define what is normal and athlete what's concerning. What's really concerning when there is something concerning, what do we do? And so for me, I'm involved in cardiac screening of athletes annually. I mean, I'm looking at tons of EKG is on patients. Um, and it's still that document. I go back to so frequently to say, okay, that I see that on the ECG, let me pull up and see what Erin and his colleagues have said, is it, you know, is it problematic? And if so, what do I need to do with it? That type of guidance has been fantastic. And I thank you for that.
Speaker 3:Well, I'm so happy to hear that because going back to the initial Seattle criteria and then most re more recently at the international criteria, which I think is the paper you're alluding to the goal was really to provide a resource for people that are in the trenches and do all aspects of sports medicine, but find themselves then at being asked, is this athletes ECG normal? And, you know, unless you do that every day, you can't memorize all the patterns you can't memorize. Exactly. What's normal and what's admirable. So having a readily accessible resource to help with that was totally the objective from day one. So Gladys.
Speaker 2:Yeah, well done. Thank you. Um, so that's kind of looking at those genetic abnormalities. If we switch and look at some of the acquired ones, this is probably the most common question I get from my patients. Um, because honestly, if you've hit 25, 30, 35 years old, you're an elite athlete. You've been through some cardiac screening. You haven't developed symptoms that the likelihood of you having an underlying genetic issue is probably less and less by the year. Um, and what starts to take the place of that from a cardiac risk standpoint are the acquired abnormalities. And that would be, uh, will you tell us what, what are the acquired problems we look for foreign athletes?
Speaker 3:Well, so I think we can, we can consider two different types of acquired pathology, acquired pathology. That is a direct result of being an athlete and acquired pathology, that it comes independent of being an athlete that exists because of traditional risk factors. And so the two best examples, uh, in those two camps would be atrial fibrillation, which is a very common arrhythmia in endurance athletes and coronary artery disease, which is the most common reason why athletes over the age of 35 die. So let's talk about atrial fibrillation, first atrial fibrillation, which is an abnormal heart rhythm that, um, again, we see very commonly in endurance athletes is the best example we have of a, of an overused pathology. And that is that as we age, if we continue to push our bodies hard, it's something we know we're at more risk for than people that sit on the couch. And so when people ask me, what's what damage can I do to myself from exercising? Um, the only responsible disease I know of that's triggered by exercise is atrial arrhythmias with eight being the most common.
Speaker 2:Do you think that is directly due solely to exercise or is it volume of exercise, plus some other things
Speaker 3:It's definitely a volume of exercise plus some other things. So there's the intrinsic physiology that happens during exercise and happens in the off time, which is largely a function of how the nervous system responds to years of training, but there's a whole host of other things that go into it. And many of which are kind of lifestyle factors, alcohol consumption, caffeine, psychosocial stress. And when you take care of enough endurance athletes where they fit in, we realize that it's never just one thing. It's always kind of an amalgam, a perfect storm, if you will.
Speaker 2:Yeah. Yeah. So I actually heard, um, I heard one of your lectures years ago where you talked about waiting in line at a race for the port of John and the rehearsal. And that really struck me that, um, the athletes that we're working with who are at high risk for AFib have a high training volume. I mean, they may be ultra athlete, ultra runners. They may be Ironman triathletes. They're usually hard charging athletes, but they're hard charging outside of athletics as well. And those, those hard charging behaviors are established risk factors for AFib. Um, do you wanna tell that a version of that story? Cause I think it's really funny.
Speaker 3:Well, can, can we save the story for when we talk about coronary disease, because that's where it's most poignant, but the analogy could be directly applicable to aphid as well. And that is, if you, if you're standing around listening to a group of 50 year old endurance athletes talking about things, they're going to describe a hard charging lifestyle, both while they're training and all, and also in the other 22 hours of the day where they're pushing hard at work, they're trying to be the best parent they can possibly be. They're burning the candle on both ends. They're drinking lots of caffeine and they're having a couple of beers at night to relax. So they, the equation starts to add up there. And so, you know, you know, the phenotype,
Speaker 2:Absolutely. So those patients who are concerned, you know, maybe they're Ironman, triathletes, maybe they're, um, you know, cyclists, but they recognize they have a really high training volume. You call it 15, 20, 30 hours a week if it's a professional. Um, and they are concerned in their thirties and forties about mitigating the risk for potential AFib. What is the best advice that, that you give them in that scenario?
Speaker 3:So two types of advice, one is related to the way they train and race. And the second it gets back to the lifestyle factors we were just discussing. I think that the most important thing as we get older is to be very deliberate about building in rest and recovery and rest and recovery needs to be thought of on the micro level and the macro level. So on the micro level, once you're above the age of 35 or 40 to think you can have more than two days a week of high intensity work is wishful thinking the body just simply can't recover after really hard workouts that quickly, once you've gotten into your third, third or fourth decade of life. So a weekly training plan that respects that and places emphasis on kind of lower intensity high volume work on the other days of the week makes a big difference. The second thing is to think about the macro and that is to look at a 12 month cycle and to really build in. And again, I don't have science to substantiate this. This is just all based on having watched it go well and watched it go wrong many times building in at least three months of, of being in a phase of active recovery. And that can be in the periods after big races that can be in between per year. Right? And we in our program define that as a reduction in volume at, by 50% and the avoidance of intensity. So, you know, and for most endurance athletes, it's not that hard to do that. They, they train up for one or two big events a year and in the bricks leading up to those events, they need to have some down weeks and after the event, they need to have a substantial period of recovery. It's the people that don't adhere to the concept of recovering both on the micro in the macro that tend to get into trouble with arrhythmias.
Speaker 2:Yeah. Which is, I mean, we can all kind of conceptually grasp that from musculoskeletal injury too, because the same applies, you start to really push too hard, too hard and you never let off the gas. And eventually you, you strain something, you sprain something, you pull a muscle like it, it happens across the board. So there's no reason to think the heart would be immune to that. And I want to make a point here to the listeners because you know, we've got video here and we're chatting. They can't see you. Aaron's a super fit guy. He's not like an, a fast runner. So it's not like he's sitting there telling people, Oh, you got to take three months off. You gotta, you gotta go easier on yourself. And you know, he's given lectures and smoking cigarettes and doing stuff on the side, like, cause we've all seen those doctors, right. They give this advice to an athletic population and they don't follow it and they don't fit the, the bill of someone we really can, can trust on the topic. That's not you. I mean, you, you train pretty hard.
Speaker 3:Yeah. And to be fair, I'm I'm I also fit that kind of hard charging personality outside of my training. So to be totally honest to the listeners, um, I tried very hard to adhere to the things that I talked to my athletic patients about. And at the same time, realize that it's always a work in process. Right. I have to remind myself on a weekly basis that, you know, I did five by one miles on the road yesterday, today is not a day that I can run hard no matter what I feel. Right. And so it's a lot of it is about kind of repatterning and rewiring your brain as you get a little older, to think about the best way for long-term success. And really it's mostly about dialing back the majority of the time. And then just keeping the volume as the, as the foundation,
Speaker 2:Have you used any of the wearables, whether it's an Apple watch or an, or a ring or whoop that kind of help give you some insight into, uh, how recovered you are the next morning?
Speaker 3:Yeah. I mean, I've been involved in beta testing for a lot of these products as they've come to market and, and have used many of them in my own, um, training and kind of living. And I'll say that, um, two things that I think are very useful, anything that provides you with an objective metric of recovery and heart rate variability is one way of doing that. Just simply checking your resting morning pulses and other way of doing that is incredibly useful. And I will tell you in the kind of the, the anxiety and the stress of the COVID pandemic, I've actually found it harder to recover from workouts. And I think that there's something to be said for the stress outside of exercise, being a big issue for many of us during this period of time. And the second thing I think is really useful is just simply going back to basics of heart rate monitoring during exercise and understanding how you can use that to make certain that on your, on your easy days, you stay easy, right? Most of us, if we're left to self-regulate and we go out for an hour run or a two hour ride, we tend to find this, this zone of intensity that sits right at our mental Tory threshold. It's enough to make us feel really good at the end of the ride, but it's not slow enough to allow us to recover. And it doesn't count for a high intensity day you're in a no man's land. Right. And aside from the fact that you're happy you had a good ride or a run, it's not moving you in a measurable way toward becoming a fitter athlete.
Speaker 2:Yeah. Yeah. That's a great point. And especially to do that in a period of time where maybe you're not sleeping as well, you're stressed in the other 22 hours of your day, it starts to become counterproductive. And you know, maybe it's good for a stress outlet, like you said, but if it's wearing down the machinery, then that's only a short-term benefit and long-term, it's gonna fall apart.
Speaker 3:Yeah. I'll just give you a quick anecdote. I, what I do with my own training and I, and I think a lot of other people do this as well as we allow it to occupy different spaces based on the world around us. So there are times when you have the luxury of really focusing on training for some goal, and there are times where your exercise is just as really an outlet, something to keep you healthy and sane. And when I'm in those healthy, insane modes, when I don't pay attention to how I'm working out, I will go out for seven runs in a row and run for an hour at a heart rate of 150 beats per minute, identically, seven times in a row. And that's just simply, again, it might make me feel better at the end of the day, but it's not measurably moving me toward being a fitter athlete.
Speaker 2:Yeah. Yeah, that's it, it's a really good point. I actually had a patient contact me yesterday who, um, he wears a whoop and it auto detects, uh, you know, training basically based on heart rate. And it auto detected training for him, uh, yesterday afternoon or the day before. I can't remember during conference calls because it was a really stressful period and it did not pick up his workout later that day. And I kind of chuckled and I was like, Oh man, that's, you know, that's really interesting, like interesting, funny, but that's not funny that's that is some real stress that's going on at work. And I thought it was a good cautionary tale that he pointed out. And one that we, I think, fail to realize or recognize and to have that objective feedback was really interesting.
Speaker 3:Yeah. I think, um, the numbers are very helpful. I also think that you can get too much of a good thing with the wearables. And so I think just like, we all need to have a couple of months of rest and recovery. I think it's useful for all of us to unplug for a couple of weeks every once in a while. And just to remember how to listen to our bodies, um, and that's best done during kind of the periods when you're backing off.
Speaker 2:Yeah. I tell my patients who are not pro athletes and not kind of working a training schedule around the calendar and those things that Thanksgiving to Christmas or whatever holidays you celebrate in that time. That's a great time to just set everything aside, recover, be active, like hiking, do what you want to do, but like don't train them depending on what your goals are, but that, that works well for a lot of us who are just picking and choosing some competitions and, and really just doing it to be fit and try to try to be faster
Speaker 3:And then somewhat facetiously. But I think there's something to it. You'd have to also know when you become too dependent upon your devices. Right. So when you wake up in the morning, you realize that your garment didn't charge overnight and you decide not to work out because it's not going to count if your garment doesn't track it. Like you, you know, it's probably time to take a break. Yeah,
Speaker 2:Absolutely. I've seen that in my ten-year-old already. We've had to address it. Like, you know, he's got, dad's old garments and if they're not charged, it's like, I don't want to go ride right now. He's like, you're going to ride with your friends to like, you know, do jumps and ride by the river and just go,
Speaker 3:Yeah. It's, it's funny. You mentioned that my kids have gotten into step counting during this whole COVID thing. And I'll sometimes come up and find my 12 year old and my nine year old in the bedroom at night before bed trying to get to 10,000 and I'm like, guys, just go to sleep and we'll do it again tomorrow. Right,
Speaker 2:Right. Give you a good goal. So we talked a little bit about AFib and the risk factors and ways to mitigate those risk factors. Um, and, and that, is it fair to say that those count toward any dysrhythmia, but AFib being the most common? I can't, I mean, I guess we may see some, a flutter in athletes, which that's a distinction that's going to be lost on most listeners, I think
Speaker 3:Yeah. Fit flutter. And even some atrial tachycardia for those that are with those terms are all kind of part and parcel in that discussion. Um, and those are all arrhythmias from the top of the heart that importantly don't cause sudden death. They don't cause people to pass out during exercise. They're just, they're symptomatically annoying for many people. And they're treatable.
Speaker 2:Um, ablation, is that a treatment that you recommend? A lot of these patients who want to get back to being active,
Speaker 3:Uh, ablation is one option and we do a fair bit of it. There, there are also very good medication options, but let me back up and say that the very first thing to do is identify whether there are any modifiable lifestyle factors. So I would much rather make a recommendation to back off on the Starbucks, sort of back off on the beer. And oftentimes that really works. But in people that do that and they have recurrence of arrhythmia, um, there are medication options which we can use, which are very safe, which don't affect exercise physiology. And they're also ablation options. And the only way to kind of get it when to use those is to say that it's an, it's an individualized discussion for everyone.
Speaker 2:Sure. Yeah. So if we step away from the, uh, a arrhythmias dysrhythmias and we look at, um, coronary disease, so the other main category of acquired, uh, acquired conditions in the heart. Describe that to us. What are we looking for there?
Speaker 3:Yeah. So just going back to the, the aphid versus coronary disease analogy for a minute, AC again is a, is a pathology of overused to some degree. Whereas coronary diseases has nothing to do with how much you exercise. It's a function of the risk factors that you bring to the equation. So this is where the, um, the analogy of having heard the discussion on the porta-potty line becomes relevant. And that is, it's a great story. I took a fellow of mine up to the Mount Washington road race, a number of years back. And she came from a team sport background and didn't know much about endurance athletes. And I said, just listen, and you'll hear everything you need to know about why we see these people get sick. Four guys are standing in front of us and they have this discussion that revolves around the amount of nachos and beer they had last night. The fact that they're there, that they're happy that they converted from being a cigarette smoker to a runner. That one guy's coughing saying, you know, he wished he wasn't here with a virus, but he has to run this race. So all of these risk factors that have nothing to do with their ability to run, but have to do with their overall health profile are right in front of you. And the importance to that is that first and foremost is doctors. It provides us with opportunities to reduce risk in our patients. And second reminds us that no amount of running confers or cycling or any endurance sport, confers immunity from coronary disease, if the risk factors exist. And so we can't convince ourselves that we're running fast enough, far enough cycling fast enough, far enough to not pay attention to blood pressure and cholesterol and that sort of stuff.
Speaker 2:Yeah. W which is worth pointing out because I think, I mean, it used to be actually put out there by the medical community. I can't remember the doctor's name, but basically if you could complete a marathon, you would not die of coronary disease. Right?
Speaker 3:Thomas J Basler, he was a pathologist practicing in per presented autopsy data to suggest that if you could run 42 kilometers, IE 26.2 miles, that you were immune from coronary disease. And he derive those data from traumatic deaths and runners, um, and found that he didn't have atherosclerosis and made the, made the statement that you can outrun coronary disease. And we know that's not true. I mean, we, we see, we see endurance athletes with coronary disease all the time, but in variably, if you look under the hood, you find enough explanation that has nothing to do with how much exercise. In fact, probably the best story to put this into context is the story of Jim Fixx. Many of your listeners will be familiar with who came from, uh, an atrocious family pedigree of coronary disease. His father died in his thirties, and Jim just knew that he was at risk for this. And so he ran and he ran and never came to the doctor. He died at age 53 of a heart attack while he was running, but he probably bought himself another 20 years because the running did help move the risk factors in the right direction. But again, you just can't can't get away from it eventually.
Speaker 2:So this is something that I've dealt with a couple of times this year peripherally through through friends, um, who have, have experienced tragic cases like this, where, you know, somebody they knew was very active, uh, had been training consistently for years or decades, and then just drops dead of, of, uh, a coronary event, a heart attack. Um, and the question to me is often the questions are often a couple of things. One, you know, did the exercise kill him? Like, what do you have lived longer if he wasn't doing this too? Is he going too hard? Is it, is it a matter of pushing too hard? And along with that kind of to be often get, well, how high, how high of a heart rate is safe? Right. So, and, and I feel like we may be reaching an age as athletes, where we start to pay really close attention that, that high heart rate and worry that there's something inherent in that number that becomes unsafe from a cardiac standpoint.
Speaker 3:So a lot to unpack there, let me start first with this issue of dying during exercise, so that this is a pretty well vetted concept called the exercise paradox, which basically says that anytime you exercise, you transiently increase your risk of sudden death, but the more you exercise, the less likely your total risk will be. And so another way of kind of putting that into context is if you're, if you're a routine endurance athlete and you're going to, you're going to die, suddenly it's likely to happen when you're exercising, but overall you're far less likely to die suddenly than the guy you work with, who doesn't go to the gym or doesn't ride a run. So that's an important thing to establish. Second thing is, you know, when these people die suddenly, is it real, it's sudden from the perspective of it happening at one instant, but how often is it really the first indicator of a problem? And we certainly can't talk to people that have actually died, but we have a lot of experience talking to people that have had cardiac arrest had been resuscitated. And the vast majority of them will admit after the fact that they knew something was on for a period of time and they simply attributed it to not enough sleep. Maybe I have a chest cold. And so the kind of the message for the listeners is that if there are persistent symptoms that you think might not just be easy to explain, just talk to your doctor about it, because these, these conditions, particularly coronary disease, which is the most common reason this happens, it can be diagnosed and fixed pretty easily.
Speaker 2:Yeah. Yeah. Those are, those are great points. Um, what about the, the heart rate? Because that's one, even in my own family, people often come to me and to say, I've been wearing this Apple watch and, you know, on my bike rides or whatever, I've just been trying to keep my heart rate under one 20. I don't want to go, I don't want to go too hard.
Speaker 3:Yeah. So a couple of ways of thinking through that one is if, if you're truly healthy and have no underlying cardiovascular disease, there's no reason to think about restricting your heart rate, right? We don't ever give people restrictive prescriptions that come to us that don't have heart disease. There's just no reason for that people that have established disease that have cornered disease that we have tried to fix and can't fix, or have a heart muscle problem. We will oftentimes give them a, a heart rate ceiling, which is defined individually based on what we do in the lab with them. But for people that feel healthy and have no risk factors, and there's not really any reason to restrict themselves.
Speaker 2:So if I'm coaching or advising an athlete, uh, on their training plan, um, which I don't do, I'm just throwing this out there. Um, but if I'm putting together a training plan for an athlete and he's maybe 62 years old, uh, has had no symptoms has been doing this for decades, probably on and off, like the rest of us, you know, with, with varying intensity or, or at least varying structure to the exercise, do you recommend any type of screening in someone like that? And, and at what point can you say, okay, that person's good to just follow the training plan, push through.
Speaker 3:Yeah. And someone that's healthy, asymptomatic, high functioning that has no traditional risk factors for heart disease. We don't recommend any screening if you're 62 and you've been taking blood pressure medication for awhile, or don't know your cholesterol, or maybe had a parent drop dead at age 40 from coronary disease. And indeed those people really should, and they're working with their coaches, find a doctor who can do some assessment. And the bare minimum would be the checkup blood panel for cholesterol, do some blood pressure monitoring and usually put these people on a treadmill to make certain there's no underlying coronary disease.
Speaker 2:Yeah. At that point, is it usually pretty fair assuming they pass all that to say, I recognize it's individual, but, um, just say the exercise for them is going to be it's, it's going to be better than not exercising. And having some intensity in that program is better than just kind of a low level burn
Speaker 3:If fitness is the goal. Absolutely. I think that's very safe to say it's also worth reminding people that when we talk about exercise, we want to ask ourselves why we're doing it and exercising to promote health and longevity doesn't require high intensity work. It requires literally simply meeting the physical activity of, you know, 30 minutes, five times a week of moderate intensity, but for the listeners and for our patients that want to continue to push and have some competitive goals, once they're checked out and things are squared off, there's no reason for them to avoid that. In fact, there's a lot to be said for doing that.
Speaker 2:Cool. So I want to be respectful of your time. I really appreciate you coming on, but I've got one more question for you and you kind of address this, uh, earlier on, but in, in looking at all these, uh, the kind of navigating the potential downsides to the acquired conditions are recognizing the risk there. And knowing that you're an athlete and a really a world leader in addressing these things, uh, from an academic standpoint, how do you structure your, um, your kind of interactions with the lifestyle components? You talked a little bit about modifying or moderating your training plan. Um, but what are the things you do around that to make sure that your training plan is falls on kind of a healthy foundation and it's a long-term benefits R and D benefits and not risks.
Speaker 3:Yeah, well, I wish I did it perfectly, but I can give you some things that I strive to do. One is to allow my relationship with training to ebb and flow as a function of what else is happening in my life and to not kid myself, that in the midst of an incredibly busy work schedule that I can put in 20 to 30 hours of training a week, like I might be when things are slower. So I let my exercise take different personalities. If you will, based on the world around me, I'm a big believer in routine sleep. Um, again, the science around sleep is murky, but I don't think you'll find an athlete anywhere that won't tell you that they feel better and train better when they've slept well. So I think paying attention to sleep hygiene, getting screens away from our faces for at least an hour or so before we go to bed, which is heart increasingly harder to do, but makes a big difference. Um, alcohol and moderation, um, is an, is an important thing. And I think many, many endurance athletes probably drink more than they should. Um, and I think over the long haul that can catch up with you. And I think stress reduction, which again, for those of us that charge hard and place a high premium on being excellent at everything we do can sometimes be a, an important part of staying healthy. So whether that's meditation, yoga, actually once in a while, going for a walk rather than a run or a ride, um, it makes a lot of sense.
Speaker 2:Yeah. And some of the listeners in my patients have heard me talk about the stress reduction that came with my time in Spain and kind of disconnecting from the way we do things in the U S the good and the bad and doing it there while I was there. Aaron, you were in Switzerland and I think had some of the same, uh, experiences so we can both attest to that.
Speaker 3:Yeah. I, you know, I think, um, everyone should be as lucky as we, we both have been to be able to live in a different place and unplug from our routine, uh, for an extended period of time, because the, at least for me, and I suspect you found the same, the health benefits of that experience were measurable. My training when I was living overseas, felt as good as it did when I was in my twenties. And that was just simply based on what was surrounding me.
Speaker 2:Yeah. If you go back and look at my HRV data, because like you have to play around with these, the wearables and am often wearing at least one, if not two, to kind of do some testing with them, it was, there was a stepwise function difference from landing in Spain, living there for months, and then coming back, like it, it Rose roughly 30% and stayed there until I came back to the U S so again, that in the U S was good, bad in Spain, but just the way the lifestyle sets up differently was beneficial in some ways.
Speaker 3:Yeah. So my question to you is when are we going back and why not sooner rather than later?
Speaker 2:Well, as soon as the lift, the, the travel bans, um, I'm hoping that we go back in March and if you're over there, you've got to come to Spain, we'll do some writing and running in the, uh, in the Pyrenees mountains and I'll show you around
Speaker 3:And then vice versa and the Swiss Alps, which, um, are an absolutely amazing playground. I'm going to hold you to, it sounds like a plan, buddy.
Speaker 2:Aaron, thanks for coming on. It's a good talk. I really appreciate the time.
Speaker 3:Yeah. My pleasure.
Speaker 2:This season of the podium is brought to you by heads up health. Heads-up health is a tool I use to look at all the data from my patients, whether they're pulling in sleep data, training data, blood work. I was recently asked on another podcast by the guest. If he took my phone from me, what app would I miss most? And heads up was the one that I said hands down. So I'd like to introduce you all to Dave.[inaudible] the founder and CEO of heads-up. Dave, tell us a little bit about heads up. Thanks, Kevin. Well, I come from the engineering world where we have these tools readily available to help us use data, to analyze problems. And I just didn't see those tools existing in healthcare in any meaningful way. So we've put together a dashboard that pulls in from all the sophisticated wearables or completely device agnostic or a AppleWatch within spiral strap, Garmin, my fitness pal, we integrate the continuous glucose, monitors, labor, a Dexcom. We can also pull in your lab results. And that's where we start to go a lot deeper than some of the other systems out there. And you can start to look at things like changes in testosterone levels changes in inflammation, markers changes in hormone levels. So it really pulls everything onto one dashboard. The dashboard is available to individuals or to teams just like you're using it for a very small mission-driven company, just providing powerful tools to use data, to optimize health. Yeah, the integration of all those things is what's so important to individuals and doctors like me, who, you know, I use it with my patients and use it to, to see how the different variables are ultimately impacting that patient's health. So if you want to learn more about using heads
Speaker 1:Up health as either a doctor or an individual, um, reach out to Dave, uh, you can reach him@daveatheadsuphealth.com. Dave, thanks for supporting the season. The content of this podcast is meant for general informational and educational purposes. Only all listeners should speak with their doctor or medical practitioner before implementing any change in their health care regimen. If you're currently a patient at podium and you have an established doctor, patient relationship with me, and I'm happy to discuss this with you. If you're not currently a patient of podium, nothing in this recording establishes a doctor patient relationship between us, nor does it constitute the practice of medicine or the dissemination of medical advice. Should you implement any information contained here in without consulting your own physician? You do so at your own risk. Thanks for listening to the podium, to hear more, be sure to subscribe wherever you get your podcasts. You can also follow us on Instagram and Strava until next time. Thanks for joining us.